Changing Care for the Frail Elderly: Community Based, Long-Term Care and ACOs Innovation Perspectives Series December 5, 2013

About the Alliance 501(c)(3) non-profit research foundation Mission: To support research and education on the value home health care can offer to patients and the U.S. health care system. Working with researchers, key experts and thought leaders, and providers across the spectrum of care, we strive to foster solutions that will improve health care in America.

Today’s Speaker: Dr. Joanne Lynn Joanne Lynn, MD, MA, MS Altarum Institute’s Center for Elder Care and Advanced Illness Joanne Lynn, MD, MA (philosophy and public policy), MS (evaluative clinical sciences), is a geriatrician, hospice physician, health services researcher, quality improvement advisor, and policy advocate who has focused upon shaping American health care so that every person can count on living comfortably and meaningfully through the period of serious illness and disability in the last years of life, at a sustainable cost to the community. She now leads the Center on Elder Care and Advanced Illness for Altarum Institute.

Altarum Institute integrates independent research and client-centered consulting to deliver comprehensive, systems-based solutions that improve health and health care. A nonprofit, Altarum serves clients in both the public and private sectors. For more information, visit Making it Safe to Grow Old & Frail: The Medicaring™ Reform Joanne Lynn, MD, MA, MS Director, Center for Elder Care and Advanced Illness

5 What We Want in Old Age….

6 ….What We Get While old age may always be challenging, we have made it unnecessarily terrifying and miserable.

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8 U.S. consumption (private + public) 8 Source: U.S. National Transfer Accounts, Lee and Donehower, Also in Aging and the Macroeconomy, National Academy of Sciences, 2013 Y axis, 1 = Average Labor Income Ages

9 How are we going to keep from big trouble?

10 MediCaring! Aim? Assure that Americans can live comfortably and meaningfully at a sustainable cost through the period of frailty that affects most of us in our last years

11 What We Really, Really Need… 1.The Cohort – Frail elderly 2.The Care Plan – For each frail person, at all times 3.The Services – Adapted; in-home, supportive 4.The Scope – Social services equally important 5.Local Monitoring & Management AND THE WILL TO MAKE THESE CHANGES!

12 Identification of Frail Elders in Need of Medicaring™ AND one of the following: >1 ADL deficit or Requires constant supervision OR Expected to meet criteria in 1-2Y Unless Opt Out Frail Elderly Want a sensible care system Age >65Age >85 With Opt In

13 A Good Care Plan

14 How important is it? A good care plan at all times is the keystone of good care 14 Services without a plan are reactive, dangerous, and terrifying

15 And then evaluate  For individuals –  Presence  Known by all affected, continues across settings, implemented  Satisfaction with the process  Patient/client report: helping to pursue goals  Patient/client report of confidence  Outcomes (life lived) evaluated against priority values  For systems –  Regular performance for individuals  Feedback upstream – self-correcting process  [use of care plans to manage the service supply and quality] 15

16 Articulated Values Plan Implement Outcomes Goals Integration Feedback About Customized Service Plans Evaluation of Quality

17 What about an "Advance Care Plan?"  Natural to consider lifespan and dying as part of care planning  Include emergency plans like POLST  Designate surrogate decision-maker(s)  Document along with care plan  Update and feedback as for other plan elements

18 Geriatricize Medical Care  Continuity  Reliability, 24/7 to the end of life  Enabling self-management around disabilities  Respecting and including family and other caregivers  Attend to the burden of medical care  Move services to the home  Prevent falls, wrong actions  Enhancing relationships, activities, meaningfulness  Enduring dementia

19 Health-service and social-services expenditures for OECD countries (%GDP ) BMJ Qual Saf 2011;20:826e831.

20 Health-service and social-services expenditures for OECD countries (as Ratio – 2005) BMJ Qual Saf 2011;20:826e831. US level

21 Disaster for the Frail Elderly: A Root Cause Social Services Funded as safety net Under-measured Many programs, many gaps Medical Services Open-ended funding Inappropriate “standard” goals Dysfx quality measures No Integrator Inappropriate Unreliable Unmanaged Wasteful “care”

22 Local level– not just state/federal (and provider)  Frail elders are tied to where they live  Local leadership responds to geography, history, leadership  Localities can engender and use largely off-budget services  Localities can address environmental issues  Localities can address employer issues for caregivers  Local management is politically plausible now

23 Encourage Geographic Concentration? YES!  Services to homes will be more efficient if allowed to be geographically concentrated  Can utilize local strengths, solve local issues  However - Must address risks of monopolies

24 What will a local manager need?  Tools for monitoring – data, metrics

25 Cincinnati Area Readmissions Over Time

26 Patient- Reported Pursuit of Goals Uneven interval, multiple reporting strategies

BÄTTRE LIV FÖR DE MEST SJUKA ÄLDRE I JÖNKÖPINGS LÄN – KOMMUNER OCH LANDSTING TILLSAMMANS [better life for the elderly people in Jonkoping}

Äldres läkemedelsanvändning i Jönköpings län Jonkoping hospitals and municipalities

Pressure ulcer rate for People living in service homes Pressure ulcer risk assessment In service homes

30 A Model Service Production System  What inputs would you need to optimize service production?  What follows is a “proof of concept” - many important elements not yet included  With good care plans for a population, one could model the production system.

31 “Alpha” Optimal Production System – How many frail elderly?  In a community of 600,000 residents, about 6000 die each year, about 5000 in old age  2500 – single overwhelming disease  2500 – frailty  Substantial self-care disability will last an average of 2 years before death  Thus, at any one time, about 5000 frail adults >65 years of age will be in need of supportive services

Frail Elders 4000 Community Residents 2500 Family Provided Care 1500 Community Provided Care 1000 Nursing Home “Alpha” Optimal Production System – Where, what & how will needed care be provided? Currently without pay and with little or no training or support! Attendance around the clock and 3 hours direct services daily Needs that cannot reasonably be met in the community

33  Number of home visits  4000 people living with serious frailty in the community  Routine visit every 4 months  Urgent visit 3/year  Primary Care Provider  Can see ~10 visits/day (with assistant/driver)  ~240 days per year  The community needs 10 full-time PCPs (and 10 full-time assistants/drivers)  Plus 24/7 coverage for urgent situations “Alpha” Optimal Production System –Primary Care Provider home visits

NH Elders4000 Community Elders Direct care workers (½-3 per user) Nurses Therapists 100 Primary Care Providers 510 PCP Assistants 10 Hospital Beds “Alpha” Optimal Production System – Summary of needs?

35 What will a local manager need?  Tools for monitoring – data, metrics  Skills in coalition-building and governance  Visibility, value to local residents  Funding – perhaps shared savings  Some authority to speak out, cajole, create incentives and costs of various sorts  A commitment to efficiency as well as quality

36 Frail Elderly People Need Some New Spending… $ Housing $ Nutrition $ Personal Care $ Caregiver training, respite, income $ New drugs and other treatments Where will it come from?

37 My Mother’s Broken Back

38 “The Cost of a Collapsed Vertebra in Medicare”

39 Estimating Potential Savings in Medical Care  Estimate frail as 10% of >64 population in a geographic area  Estimate PMPM total costs (except for unpaid caregiving)  Use CMS HRR and county data for aggregate costs, population, utilization  Use sources in literature for LTC costs and small ancillary costs  Estimate realistic goals of reducing medical care, delaying Medicaid, reducing use of nursing homes - generally, about half of the maximal effect (e.g., 25% reduction in hospital, 5% in LTC)

40 A Winning Possibility: MediCaring ACOs…  Four geographic communities - 15,000 frail elders as steady caseload  Conservative estimates of potential savings from published literature on better care models for frail elders  Yields $23 million ROI in first 3 years Net Savings for CMS Beneficiaries Yr 1Yr 2Yr 33-Yr Before Deducting In- Kind Costs -$2,449,889$10,245,353$19,567,328$27,362,791 After Deducting In- Kind Costs -$3,478,025$8,463,101$17,629,209$22,614,284 For more on financial estimates, see

41 But how to motivate the changes … and sustain them?  3 rd year – convert to a special purpose ACO  Allowed to enroll only frail elderly persons  Only those who live in a particular area  Measured by population well-being and costs, as well as enrollee experience  Plans of care on-line, used, feedback upstream, and regulating the production system  Dashboard to monitor local quality and costs  Governance and authority can be local government, voluntary coalition, or strong lead organization – needs testing

42 CCustomize services for frail elderly cohort GGenerate good patient-centered care plans AAdapt medical care IInclude long-term services DDevelop local layer of monitoring and management Channel the fear and frustration into the will to change MediCaring! Key Components of Reform Geriatricize

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44 Useful resources  For Data  (check out Cincinnati)  Your QIO – (ask for help with “care transitions”) tPublic%2FPage%2FQnetTier2&cid= tPublic%2FPage%2FQnetTier2&cid=  Trends-and-Reports/Medicare-Geographic-Variation/ Trends-and-Reports/Medicare-Geographic-Variation/  For Community Organizing   For Workforce in Elder Care   For more on Financing 

45 A look into frailty Photo credits:

Discussion & Questions Submit questions to “Teresa Lee” at the Fuze Chat Box. Presentation slides will be available at perspectives perspectives

Thank You!